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Based record review, observations, and interview, the Governing Body (GB) failed to ensure the facility:


A. incorporated data concerning patients identified as positive for the COVID-19 infection during their admission to the facility into the Quality Assessment and Performance Improvement Program (QAPI). The facility failed to collect, measure, analyze, or track any data related to COVID-19 or COVID-19 positive cases in the facility. The facility had 13 COVID-19 positive cases inpatients for the month of July 2020. The facility had no monitors in place to ensure safety, quality, effectiveness of care, or prevention of COVID-19 infection.

Refer to Tag A0273


B. monitored the process for COVID-19 prevention for use of mask or screening to prevent the spread of COVID-19 in the facility. There were no improvement processes put in place for the failed processes, allowing safety measures to be put in place for patient and employee safety during a pandemic.

Refer to Tag A0297



C. followed its own Staffing Plan to evaluate staffing needs based on patient acuity-established criteria and anticipated admission, transfers, and discharges for 31 out of 31 days reviewed (from 7/1/2020 to 7/31/2020).


D. have adequate and safe staffing for nursing to ensure patients received full assessments, adequate time to conduct admissions and discharges, adequate time and staff to care for ill patients in isolation, monitor patients with high risk behaviors, supervise staff, ability to take breaks, and meet the needs of all patients for 21 out of 62 shifts reviewed (from 7/1/2020 to 7/31/2020).

Refer to Tag A0392



E. had policies and procedure for nursing care of the COVID-19 patients, COVID-19 exposures, and isolation of the COVID-19 patient to ensure nursing had clear instruction for assessments and care of 18 out of 18 patients (Patient #s 1 through 81) with known or suspected COVID-19.


F. nursing performed an appropriate screening of COVID-19 symptoms or exposures, educate patients on COVID-19 signs and symptoms, document signs and symptoms of COVID-19 and address in the treatment team plan in 2(Patient #1 and #6) of 2 chart reviewed.


G. nursing was assessing patients change of conditions, falls, pain levels, and reporting to the physician in 2(#1 and #6) of 2 patient charts reviewed.


H. nursing documented on a nursing plan of care the patient's change in condition, positive COVID-19 diagnosis and treatment, isolation, falls, antibiotics, medication changes, IV fluid administration, oxygen administration, increased confusion, pain, and patient's response to treatment or interventions in 2 (Patient #1 and #6) of 2 charts reviewed.

Refer to Tag A0395


I. nursing documented on a nursing plan of care the patients change in condition, positive COVID-19 diagnosis, treatment, isolation, falls, antibiotics, medication changes, IV fluid administration, oxygen administration, increased confusion, pain, and patient's response to treatment or interventions in 2 (Patient #1 and #6) of 2 charts reviewed.

Refer to Tag A0396


J. conducted a facility-wide risk assessment specific to COVID-19 in order to properly assess and evaluate potential COVID-19 risks specific to each of the facility departments/operations.


K. used findings from a specific facility risk assessment and national COVID-19 standards (such as guidelines from the Centers for Disease Control) to develop a comprehensive COVID-19 response plan, policies, and/or procedures for facility staff to follow.


L. developed, implemented, and enforced Transmission-Based Precautions for known and suspected cases of COVID-19 for 18 out of 18 patients (Patients # 1 through #18) with known or suspected COVID-19.


M. provided education to patients, family, and staff members on COVID-19 symptoms to report per national COVID-19 standards.


N. screened patients, visitors, and staff member for COVID-19 symptoms per national COVID-19 standards prior to entering the facility.


O. enforced the processes that had been established by the facility related to COVID-19.


P. established quality monitors for the tracking of COVID-19 related symptoms and processes to ensure early detection and comprehensive interventions to prevent the spread of COVID-19 among all patients and staff.


The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to Tag A0749

Based upon record review, observations, and interview the facility failed to:


A. incorporate data concerning patients identified as positive for the COVID-19 infection during their admission to the facility into the Quality Assessment and Performance Improvement Program. The facility failed to collect, measure, analyze, or track any data related to COVID- 19 or COVID-19 positive cases in the facility. The facility had 13 COVID-19 positive cases in patients for the month of July 2020. The facility had no monitors in place to ensure safety, quality, effectiveness of care, or prevention of COVID-19 infection.

Refer to Tag A0273


B. monitor the process for COVID-19 prevention for use of mask or screening to prevent the spread of COVID-19 in the facility. There were no improvement processes put in place for the failed processes, allowing safety measures to be put in place for patient and employee safety during a pandemic.

Refer to Tag A0297

Based on review of records and interview, the facility failed to incorporate data concerning patients identified as positive for the COVID-19 infection during their admission to the facility into the Quality Assessment and Performance Improvement Program. The facility failed to collect, measure, analyze, or track any data related to COVID- 19 or COVID-19 positive cases in the facility. The facility had 13 COVID-19 positive cases in patients for the month of July 2020. The facility had no monitors in place to ensure safety, quality, effectiveness of care, or prevention of COVID-19 infection.

Findings:

An interview with Staff #2 was conducted in the afternoon of 7/29/20. Staff #2 stated, she did not have any data, indicators, or performance improvements for patients in isolation or COVID-19. Staff #2 confirmed the first COVID-19 positive was an employee on 7/3/20.

On the morning of 8-7-2020 an interview was conducted in the conference room with Staff #1, Staff #2, Staff #13, and Staff #14 present. Staff were asked who in the facility was assigned and responsible for monitoring the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) websites for updated COVID-19 Guidelines and Recommendations.

Staff #13 stated that the corporate Infection Control Specialist was the person who monitored those websites and updated facilities on changing recommendations and guidelines. Staff #2 was asked if she monitored the websites and made recommendations to the corporate Infection Control Specialist. Staff #2 stated that she looks at the CDC website occasionally but confirmed that she did not make any recommendations based off the information she reviewed.

Staff #2 was provided a copy of the CDC pamphlet titled, "Comprehensive Hospital Preparedness Checklist for Coronavirus Disease 2019 (COVID-19)". The purpose of the checklist was:

"Planning for a community outbreak of Coronavirus Disease 2019 (COVID-19) is critical for maintain healthcare services during a response. The Centers for Disease Control and Prevention (CDC), with input from partners, has developed a checklist to help hospitals (acute care facilities) assess and improve their preparedness for responding to a community-wide outbreak of COVID-19. Because of variability of outbreaks, as well as differences among hospitals (e.g., characteristics of the patient populations, size of the hospital/community, scope of services), each hospital will need to adapt this checklist to meet its unique needs and circumstances. This checklist should be used as one of several tools for evaluating current plans or in developing a comprehensive COVID-19 preparedness plan. Additional information can be found at www.cdc.gov/coronavirus."

Staff #1 and Staff #14 confirmed that they had not seen the checklist before and that an assessment of the facility's physical environment and operations had not been evaluated using the checklist or a similar checklist designed to analyze and prepare facilities for a COVID-19 outbreak.

A second interview was conducted on 8-7-2019 with Staff #2. Staff #2 again confirmed that no data tracking or formal process improvement projects were initiated as a result of the increasing positive COVID-19 patients and staff in the facility during the first three weeks of July.

Based on record review and interview, the facility failed to monitor the process for COVID-19 prevention for use of mask or screening to prevent the spread of COVID-19 in the facility. There were no improvement processes put in place for the failed processes, allowing safety measures to be put in place for patient and employee safety during a pandemic.


Review of the Performance Improvement Committee Meeting minutes held on July 16,2020 revealed the 2nd quarter of the year (April, May, and June) was being reviewed. Review of the minutes revealed there was only three things being reviewed for performance improvement in infection control as follows:

Hand Hygiene Surveillance
Goal: 100% Actual: 100%

HAI (Hospital acquired infections)
Goal: 0 Actual: 0

Multi-drug Resistance Organisms:
Goal: 0.0 Actual :0


The facility had no positive cases of COVID-19 in the 2nd quarter but was mandating the use of mask at all times in the facility starting 4/2020. The facility had implemented employee daily screening and patient screenings upon admission.


An interview with Staff #2 was conducted in the afternoon of 7/29/20. Staff #2 stated, she did not have any data, indicators, or performance improvements for patients in isolation or COVID-19 positive cases for any of the quarters of 2020. Staff #2 confirmed the first confirmed COVID-19 positive was an employee on 7/3/20.



40989

On 7/29/2020 at 9:05 AM, surveyors entered the facility. It was noted in the main lobby of the facility there was no hand sanitizer readily available to staff or visitors entering through the main entrance. The surveyor also observed Staff #5 was providing new employee orientation to one staff member in a conference room in the administration department. Staff #5 and the new employee were observed not wearing a mask or face covering and no social distancing was observed.

An interview was conducted with Staff #1 and Staff #2 on 7/29/2020 after 9:30 AM. Staff #2 was asked if the facility had a screening process in place for visitors and staff that had to be completed upon entering at the front lobby. Staff #2 replied, "Yes we do. Anyone that works up front comes through the front door and checks their temperature and logs it in a notebook. Clinical employees, Nursing and Mental Health Techs, enter in the back door and check their own temperatures and log it in a book. Sometimes the charge nurse does the temperature checks on the employees and she will log it into the book."

Staff #1 was asked if there were any screening questions asked regarding symptoms or exposure to COVID-19 to employees and visitors. Staff #1 stated, "All of the employees had to complete a questionnaire in June regarding symptoms or exposure to COVID-19, but it is not completed daily. We only take temperatures daily. The employees are told to contact the Infection Control Nurse or their direct supervisor if they become symptomatic."
Staff #2 confirmed no screening temperatures were logged on any employee entering through the back entrance on May 16, 2020 through July 1, 2020, and July 3, 2020 through July 13, 2020. In addition, no temperature screenings were completed on July 15, 16, 18, or 19, 2020.

Staff #2 confirmed she does not regularly monitor the screening tools used.

Review of a document titled Oceans Healthcare COVID-19 Response Timeline showed that, on 4-28-2020, Oceans Healthcare was to implement "universal masking" that required all employees to wear a face mask while in the hospital. On 5-15-2020, Oceans Healthcare was to implement temperature screening for all employees and visitors upon arrival to the hospital and prior to work.


A review of the CDC's current recommendations, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. revealed:


"1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic.
...
Implement Universal Source Control Measures
...
HCP should wear a facemask at all times while they are in the healthcare facility, including breakrooms or other spaces where they might encounter co-workers."

Based on record review and interview, the facility failed to:

A. follow its own Staffing Plan to evaluate staffing needs based on patient acuity-established criteria and anticipated admission, transfers, and discharges for 31 out of 31 days reviewed (from 7/1/2020 to 7/31/2020)

B. have adequate and safe staffing for nursing to ensure patients received full assessments, adequate time to conduct admissions and discharges, adequate time and staff to care for ill patients in isolation, monitor patients with high risk behaviors, supervise staff, ability to take breaks, and meet the needs of all patients for 21 out of 62 shifts reviewed (from 7/1/2020 to 7/31/2020).

Refer to Tag A0392


C. have a policy and procedure for nursing care of the COVID-19 patients, COVID-19 exposures, and isolation of the COVID-19 patient to ensure nursing had clear instruction for assessments and care of 18 out of 18 patients (Patient #s 1 through 81) with known or suspected COVID-19.

D. ensure nursing performed an appropriate screening of COVID-19 symptoms or exposures, educate patients on COVID-19 signs and symptoms, document signs and symptoms of COVID-19 and address in the treatment team plan in 2(Patient #1 and #6) of 2 chart reviewed.

E. ensure nursing was assessing patients change of conditions, falls, pain levels, and reporting to the physician in 2(#1 and #6) of 2 patient charts reviewed.

F. ensure nursing documented on a nursing plan of care the patients change in condition, positive COVID-19 diagnosis and treatment, isolation, falls, antibiotics, medication changes, IV fluid administration, oxygen administration, increased confusion, pain, and patient's response to treatment or interventions in 2 (Patient #1 and #6) of 2 charts reviewed.

Refer to Tag A0395


G. ensure nursing documented on a nursing plan of care the patients change in condition, positive COVID-19 diagnosis, treatment, isolation, falls, antibiotics, medication changes, IV fluid administration, oxygen administration, increased confusion, pain, and patient's response to treatment or interventions in 2 (Patient #1 and #6) of 2 charts reviewed.

Refer to Tag A0396

Based on record review and interview, the facility failed to:

A. follow its own Staffing Plan to Evaluate staffing needs based on patient acuity-established criteria and anticipated admission, transfers, and discharges for 31 out of 31 days reviewed (from 7/1/2020 to 7/31/2020)

B. have adequate and safe staffing for nursing to ensure patients received full assessments, adequate time to conduct admissions and discharges, adequate time and staff to care for ill patients in isolation, monitor patients with high risk behaviors, supervise staff, ability to take breaks, and meet the needs of all patients for 21 out of 62 shifts reviewed (from 7/1/2020 to 7/31/2020).


Review of the staffing scheduling from 7/1/2020 to 7/31/2020 (2 shifts per day for a total of 62 shifts) revealed the following:

Mental Health Technicians (MHT's) were short on 10 dayshifts (7:00 AM to 7:00 PM) and 8 nightshifts (7:00 PM to 7:00 AM) a total of 18 shifts out of 62 shifts reviewed.

Licensed Vocational Nurses (LVN) short 3 dayshifts out of 62 shifts reviewed.


An interview with Staff #1 and 2 was conducted on the morning of 7/29/20. Staff #1 stated that they have had some difficulties with staffing due to COVID-19 and "people just don't want to work." Staff #1 stated that they have tried to recruit nurses. Staff #1 stated they were trying to use a staffing agency but when they found out we had COVID-19 patients they would not send us any agency nurses. Staff #1 provided no other evidence on how the facility was recruiting.


Staff #1 stated that they have COVID-19 patients in the facility presently but there is no separate unit for the patients. Staff #1 confirmed the same nurses and MHT's caring for the well patients were caring for the COVID-19 patients. Staff #1 stated that they are "isolating patients to their rooms but they are psych patients and sometimes they come out into the hallway and they won't wear a mask."

Staff #1 stated, "we can't force them to stay in their rooms." Staff #1 and #2 confirmed the patients have been "at times" out of their isolation in the hallways with other patients and staff. Staff #1 confirmed that the facility is actively admitting patients. Staff #1 was asked if the patients, guardians, or families were aware that there were COVID-19 patients in the facility? Staff #1 confirmed "yes" and they have agreed before we admit them.

Staff #1 was asked why were they admitting more patients when they were having staffing shortages, an outbreak of COVID-19 among staff and patients, shortage of housekeeping staff? Staff #1 was also asked how they were staffing to acuity needs? Staff #1 stated that, "what are we supposed to do when these people call and need help. We have no choice but to admit them. Where are they going to go?" Staff #1 stated that the staff are called in for 1:1's but was unable to give examples of staffing acuity levels and who determined those levels.


A tour of the unit was conducted on the morning of 7/29/20 with Staff #2. Staff #3 The Director of Nurses (DON) was unavailable and Staff #2 confirmed she would cover for Staff #3 when needed. The 7/29/20 staffing schedule showed a patient census of 14. The staff scheduled met the minimum grid for the patient census; but there were no acuity levels to determine if increased staffing was required. The staffing schedule did not include acuity identifiers for the following:

3 isolation patients (COVID-19)

1:1 patient due to falls and in isolation

1 Admission

2 Discharges

One RN was called off due to Low Census (LC); but there was nothing that showed the acuity of the patients were considered.


Review of the facility's policy and procedure "Staffing Plan" Policy number NSG-06 Revised date 7/1/19 stated, "D.O.N./ Charge Nurse Criteria for adding staff:

High acuity and high-risk patient population identified by the charge nurse. Anticipated admissions/discharges/transfers.

Scheduled special procedures: test preps. special treatment conferences.

Peak activity times on unit; partial shift coverage or full shift flex staffing.

Classification of scheduled staff (licensed versus unlicensed) versus patient needs.

Skill level of employees (i.e. new hires, float staff, etc.).

Patient activity, visitation hours, physician needs.

Scheduled in-services.


Criteria for decreasing staff:

Decrease in patient census.

Anticipated discharges on one shift will affect scheduling on next shift.

Availability of other disciplines.

Patient activities.

Level of patient needs and functioning ...

Charge Nurse after hours and weekends

Evaluates the staffing needs based on patient acuity-established criteria on a shift-by-shift basis and adjusts staff levels accordingly."


An interview with Staff #5 was conducted in the afternoon on 7/29/20. Staff #5 was assisting the surveyor with the staffing sheets. Staff #5 stated the staff are not "really on call" there is no call list to have staff available for an increase in census. Staff #5 stated that employees are called off if the beginning census was low. Staff #5 confirmed that the schedule was not staffed on current isolation (COVID-19) patients or anticipated discharges and admissions. Staff #5 was unable to speak to the acuity of the patients and how that is determined.


An interview with Staff #25 was conducted on 7/30/20. Staff #25 assisted the surveyor with the scheduling review. Staff #25 stated that she was instructed to call off staff for Low Census (LC) when the census was low, and she did not consider anticipated admissions or discharges. Staff #25 confirmed that if patients were being discharged and the staff decreased the RN should LC the staff according to the staffing matrix. Staff #25 was aware of the staffing issues and stated that she was having a hard time keeping staff on the schedule due to COVID-19. Staff #25 stated they just didn't want to work, or they worked at other facilities and were not allowed to work with active COVID-19 patients. Staff #25 was unaware of methods administration was using to retain or recruit staff. Staff #25 was unable to speak to the acuity levels and how that was determined.


Confidential interviews with staff were conducted from 7/29/20-7/30/20 concerning infection control and safe staffing. Staff did not want to be identified due to fear of retaliation. Staff stated that they had not been issued full PPE until a "couple" of days ago. Staff had been buying their own mask and hand gel. Staff confirmed the patients that had positive COVID-19 test would walk out into the dayrooms, up and down hallways with no mask on. Staff stated administration told them to redirect the patients and try to get them into the rooms, but they could not force patients to go to their rooms. Staff stated that there was not enough staff to care for the sick patients and try to keep them in their rooms. Staff felt there were safety issues with having all the COVID patients mixed in with the well patients. Staff stated there was not enough time to care for those patients, do admissions, discharges and deal with patients that would not wear their mask. Staff stated a couple of weeks ago there was 7-8 COVID patients in the building and nurses and MHT's just quit because it was too much to handle. Staff stated they reported all the issues but felt administration "didn't care."


Review of the staffing schedule on 7/14/20 day shift (7:00 AM-7:00 PM) revealed a patient census of 15. According to the Staffing Matrix, there should be 1 Registered Nurse (RN), 1 Licensed Vocational Nurse (LVN) and 3 Mental Health Technicians (MHT). A Bridge Nurse (an RN scheduled to allow for lunch breaks or assist during busy times.) was also on the matrix for 8 hours. The Matrix stated, "discretionary additional RN bridge hours allowed for both shifts."


Review of the schedule revealed that initially only one RN and 5 MHT's were scheduled. An LVN was added. One of the MHT's was crossed through leaving 4 MHT's. A note on the schedule read "seeking RN."


The facility had 3 (Patient #6, #11, and #10) positive COVID-19 patients and 3 (Patient #4, #5, and #7) patients pending for COVID-19 results at the beginning of the day shift. Six patients were in isolation and required staff to observe patients, attempt to keep them in isolation, and closely monitored by the RN. The RN was also responsible for 9 more patients that were not in an isolation status along with direct supervision of her staff. There was no bridge nurse assigned. On 7/14/20 the three-pending test all came back positive and now the RN had 6 COVID-19 positive patients to care for.


Review of the patient census sheet on 7/14/20 revealed that the day shift RN had 4 admissions and 1 discharge. Staff # 5 confirmed it takes about 2 hours to perform an admission including the paperwork. Doing admissions alone for 4 patients would have consumed at least 8 hours of the RN's time along with a discharge. According to the facility policy "Documentation" Policy # NSG-02 revised 10/1/17 stated, "The RN documents on the Daily Nurses Note, in BIRP (Behavior, Intervention, Response, Plan) format, a minimum of once per shift. The nurse needed to have the ability to observe and interact with all the patients to document in the BIRP format. The admission times were logged in on the census sheet as the following times:

Patient #15 at 8:00 AM
Patient #1 at 9:45 AM
Patient #17 at 16:15 (4:15 PM)
Patient #22 at 18:00 (6:00 PM)
Patient #16 at 23:30 (11:30 PM).


Staff #5 confirmed that there was no RN available to call in for the 14th. Staff #5 stated, there was "administration people here that helped" but was unable to give the surveyor names or times when the RN was assisted. Staff #5 confirmed at the beginning of the shift two MHT's were called off (told not to come in) due to low census (LC). One MHT was called back in at 3:00 PM for a 1:1. Now the RN had 17 patients, 6 isolation patients, 2 more admissions and a 1:1.

Based on record review and interview, the facility failed to:

A. have a policy and procedure for nursing care of the COVID-19 patients, COVID-19 exposures, and isolation of the COVID-19 patient to ensure nursing had clear instruction for assessments and care of 18 out of 18 patients (Patient #s 1 through 81) with known or suspected COVID-19.

B. ensure nursing performed an appropriate screening of COVID-19 symptoms or exposures, educate patients on COVID-19 signs and symptoms, document signs and symptoms of COVID-19 and address in the treatment team plan in 2(Patient #1 and #6) of 2 chart reviewed.

C. ensure nursing was assessing patients change of conditions, falls, pain levels, and reporting to the physician in 2(#1 and #6) of 2 patient charts reviewed.

D. ensure nursing documented on a nursing plan of care the patients change in condition, positive COVID-19 diagnosis and treatment, isolation, falls, antibiotics, medication changes, IV fluid administration, oxygen administration, increased confusion, pain, and patient's response to treatment or interventions in 2 (Patient #1 and #6) of 2 charts reviewed.


Findings:

Patient #1

Patient #1 was admitted on 7/14/2020 as a voluntary patient with a diagnosis of Neurocognitive Disorder and a history of Dementia. There was no documentation found that the patient or his family were informed there were COVID-19 positive patients in the facility at the time they were seeking admission.

Review of the patient census for 7/14/2020 showed that 6 patients (Patient # 4,5,6,10,11 and 14) were positive for COVID-19. The facility admitted 5 patients (Patient #1,15,16,17, and 22) the same day, 7/14/2020.

Review of Patient #1's chart revealed a "Patient Screening for COVID-19" form. The form had the date (7/14/2020) and patients name at the top. The form stated, "All patients will be assessed for illness and/or exposure to 2019 Novel Coronavirus (COVID-19). The form asked the following 4 questions as follows:

"Fever (100F orally or higher) Then asked for the Temperature and Route.
Symptoms of respiratory infection, such as a cough and sore throat.
Travel outside of the country within the last 14 days.
Contact with someone with known or suspected COVID-19."


The "Patient Screening for COVID-19" form was signed by an employee identified as a marketer. There was no information on who gave her this information. The Temperature and Route was blank on the form. There was no other information found concerning symptoms or possible exposure to COVID-19 documented in the chart.


Review of Patient #1's Multi-Disciplinary Note dated 7/14/2020 at 1510 (3:10 PM) revealed the patient was having chest pain and vital signs (V/S) "B/P 193/106 HR 89 R 18 T 98.4." The physician was notified and ordered Nitroglycerine sublingual and an EKG. Patient #1 stated the chest pain resolved at 1528 (3:28 PM). There was no further documented assessment concerning the chest pain or vital signs documented after 1510 (3:10 PM) on 7/14/2020. Review of the "Observation Check Sheet/ Graphic Flowsheet revealed vital signs were taken between 7:00 PM and 7:00 AM but there was no time documented. The vital signs were "T-97.7, Pulse 57, Resp. 20, O2 sat 98 and a blood pressure of 166/99." Patient #1's B/P was still elevated and there was no evidence that the physician was notified. Review of Patient #1's Observation Check Sheet/ Graphic Flowsheet revealed 23 out of 34 shifts did not have a documented time when vital signs were taken and documented.


According to the American Heart Association the Normal adult blood pressure is systolic of less than 120 and diastolic of less than 80 (120/80) Pulse rate Adults (age 18 and over) 60 - 100 beats per minute.


Patient #1 was tested for COVID-19 per Nursing Home request before he could be discharged on 7/24/2020. Review of the Nurses notes for both shifts revealed there was no documentation when the test was performed, who performed the test or how the patient tolerated the test.


Review of Patient #1's physician orders revealed an order on 7/24/2020 at 1633 (4:33 PM) to place the patient in contact isolation due to a positive COVID-19 test. There was no nursing documentation on the day shift or night shift concerning the patient being placed in isolation, if the patient understood his diagnosis, any education done with the patient concerning his new diagnosis and isolation procedures, or how the patient tolerated the process. Review of the isolation policy and procedure revealed there was no update to the policy to include COVID-19 and isolation requirements for the facility.


Review of the Daily Nurse Note dated 7/25/2020 at 10:36 AM revealed the patient had no symptoms from COVID-19 documented. Patient #1 had vital signs within parameters. Nurse documented that patient "wanders out to hallway" and was "pacing in his room." There was no documentation that the patient was wearing a mask.


Review of the Multidisciplinary Notes on 7/25/2020 at 11:05 AM the nurse documented, "Pt found in his bathroom with lights off on the floor. Pt confused and in contact isolation. Pt had unwitnessed fall-pt states he hit his face and tried to get back up and hit his back. Pt found with partial pants down his leg stating Help me! Help me! I was trying to take a shower! Skin assessment done-small laceration noted to his right thumb. Pt requested to lay down assisted pt. to bed-placed bed alarm monitor and notified physician. There was no documentation found on assessment of range of motion to joints or the patients pain level.


Review of Patient #1's physician orders revealed an order on 7/25/2020 at 12:04 PM. The order read, "Pt. to be a 1:1 due to isolation and increase fall risk for 24 hrs. while awake." (1:1- the patient is visually within sight and within arms-reach of a staff member at all times and in all circumstances.)There was no documentation found on the nursing plan of care that the patient had a fall with injuries. There was no documentation that the patient was placed on a 1:1.


Review of Patient #1's physician orders revealed the nurse practitioner ordered the patient to be put on Zithromax (antibiotic), Prednisone (steroid), Pulmicort Inhaler (corticosteroid), Vit C and Zinc (vitamins). There was no documentation on the treatment team notes or nursing plan of care of the new medication and administration of an antibiotic.


Review of the Physician orders dated 7/25/2020 at 1446 (2:46 PM) the nurse practitioner wrote "Start IV NS @ 125 cc/hr x 1ltr (liter)-do not DC IV until reassessed." There was no documentation on the order or in the nurse's notes that gave a reason why Patient #1 was receiving an IV of normal saline. The nurse practitioner documented on her 7/26/2020 progress note that the patient was receiving fluids due to poor intake. Review of the nurses notes from admission to discharge stated the patients "Nutrition/Fluid: Adequate." There was no nursing documentation or assessment that discussed the patient's poor "po (oral) intake." Review of the treatment plan and nursing plan of care revealed no documentation of the patient's poor intake or IV therapy.

Review of the Daily Nurses Notes on 7/27/2020 at 12:45 PM revealed Patient #1 now had a cough. Patient #1 had an elevated blood pressure of 167/96 and was confused. He was now being prompted for nutrition and fluids. Patient #1 has had a change in condition. The nurse practitioner saw the patient at 12:27 PM but there was no documentation that there was a cough and no documentation that she or the physician was notified. On 7/27/2020 the nurse practitioner saw Patient #1 again and there is no documentation of cough. The nurse practitioner stated the lungs were clear to "auscultation (the listening of lung sounds with a stethoscope) and good air entry."


Review of the Observation Check Sheet/Graphic Flowsheet revealed on 7/27/2020 at 1907 (7:07 PM), Patient #1 had a temperature of 100.2. There was no documentation in the nursing notes that the patient temperature was addressed or if the physician was notified of the change in condition.


On 7/29/2020 at 10:20 AM, a tour was conducted with Staff #2. Staff #4 a Mental Health Technician (MHT) was standing outside (in the hallway) of Patient #1's room (4B) in a disposable gown, shoe covers, gloves, N95 mask, head bonnet, and face shield. Staff #4 stated, she was on a 1:1 with the patient due to a fall. Staff #4 stated the patient was COVID-19 positive and she had to stay by the patient's door with the door open, so she could see him. Staff #4 stated, the patient had been confused and had been difficult to keep in his room. Staff #4 stated, the patient had been out in the hallway with no mask several times, but the staff tried to intervene.


The surveyor observed Patient #1 was coughing in his room and had no mask on. He called the tech into the room and showed her he had coughed up some blood in a Kleenex. The tech called for the nurse.


Staff #6 did not take any equipment into the room. She talked to the patient and asked him questions. Staff #6 never took any vital signs or assessed the patient's lung sounds. The surveyor asked Staff #6 about 10 minutes later if she planned to assess Patient #1 and perform vital signs. Staff #6 instructed Staff #4 MHT to go into the room and take Patient #1's vital signs. Staff #4 brought a cart with the sphygmomanometer (instrument to measure blood pressure), thermometer, and pulse oximetry attached to Patient #1's room and took the patients vital signs. The surveyor did not observe Staff #6 assess Patient #1's lung sounds before her documentation at 11:30 AM. The nurse failed to perform a thorough assessment. The nurse was unable to give the physician a clear and concise report to the physician without assessing the patient's lung sounds.


Review of the Multi-Disciplinary Note dated 7/29/2020 at 11:30 AM Staff #6 documented, "Pt. assessed due to spitting small amount of bloody mucus. Pt in no distress- denies pain or SOB. Notified_____ (nurse practitioner) pt. to be cont to be monitored. Repeat vs b/p 145/84, p-73 O2 99 R-20 T-98. No new orders at this time." (sic)


Review of the Multi-Disciplinary Note dated 7/29/2020 at 1620 (4:20 PM) revealed Staff #6 documented, "Pt states feel a little better. BP 133/80, R, 20, O2 99% T101.2 Tylenol given prn for temp." Patient had an active bloody cough and later developed a temperature of 101.2 with no evidence that the physician was notified.


Review of the Multi-Disciplinary Note dated 7/29/2020 at 2012 (8:12 PM) the nurse documented the patient's oxygen saturation had dropped to 68% with a temperature of 103.2. The physician was called and an order for Oxygen 4L by nasal cannula was ordered. The nurse documented, "Pt was compliant with Tylenol, but continuously removed the NC (nasal cannula)." The nurse documented in the Daily Nurse Note at 2216 (10:16 PM) Pt agitated, constantly trying to get up. Stated "I hope to God one day you suffer like this." There was no documentation that the physician or the nurse practitioner came to the facility and assessed Patient #1.


According to the American Lung Association an oxygen level greater than 90% may be considered normal; anything below that would be a reason to call a doctor, and anything under 89% would be a reason to go to the emergency room.


Review of the Multi-Disciplinary Note dated 7/30/2020 at 6:30 AM the nurse documented, "Monitored the patient throughout the night. O2 sat stayed between 79% and 82%. Pt remained verbally aggressive and removed NC several times. MHT attempted multiple times throughout the night to keep NC in place. Raised HOB, attempted to calm patient and encourage deep breathing. Continued O2 monitoring throughout the night. _____ (physician) notified that O2 sat came up to 82%. Pt was in no apparent distress, slept through the night."


Review of the physician orders revealed a verbal order, from the nurse practitioner, dated 7/30/2020 at 7:51 AM stated, "Pt. to be sent to ER due to decreased O2 sat of 74% and hypoxia."


Review of the Multi-Disciplinary Note dated 7/30/2020 at 8:03 AM revealed Staff #6 documented the patients O2 sat to be "89%." Pt was discharged to the local hospital on 7/30/2020 at 8:25 AM.


Confirmation from the local hospital revealed Patient #1 had been admitted directly to the Intensive Care Unit upon arrival and died on 8/6/2020 @ 2345.


Patient #6

Review of Patient #6's chart revealed, he was an 89-year-old male from a Nursing Home in Kilgore. He was admitted on 6/24/2020 for agitation, verbally and physically aggressive, and tried to choke a staff member at the Nursing Home. Patient #6 was admitted voluntarily. On the Daily Nurses Note, dated 6/25/2020 at 9:43 AM, that the patient was "confused" and had "word salad." The social worker documented on 6/24/2020 that the patient was unable to answer questions due to cognitive impairment. Review of Patient #6's physician orders revealed he was admitted with a diagnosis of Bipolar I disorder with psychotic features and altered mental status unspecified. He was placed on assaultive precautions and 15-minute checks by the staff.


Review of the chart for Patient #6 showed it contained a "Patient Screening for COVID-19" form. The form had the date, 6/23/2020, and patient's name at the top. The form stated, "All patients will be assessed for illness and/or exposure to 2019 Novel Coronavirus (COVID-19). The form asked the following 4 questions as follows:

"Fever (100F orally or higher) Then asked for the Temperature and Route.
Symptoms of respiratory infection, such as a cough and sore throat.
Travel outside of the country within the last 14 days.
Contact with someone with known or suspected COVID-19."


The "Patient Screening for COVID-19" form was signed by an employee identified as a marketer. There was no information on who gave her this information. The Temperature and Route was blank on the form. There was no other information found concerning symptoms or possible exposure to COVID-19 documented in the chart. There was no further COVID-19 testing information documented.


Review of patient #6's Multi-Disciplinary Notes dated 6/30/2020 at 4:20 AM stated, "Pt c/o (complained of) lower abdominal pain. MHT reports dark blood coming from penis. Pt able to void in dribble manor(sic). Pts bladder distended and winces when lightly palpated. Dr.____ (physician) notified. N.O. (new order) noted. 16 Fr Coude cath (a device inserted into the bladder to collect urine) inserted with indwelling cath return of dark bloody urine est 1300 cc. Urine obtained for UA (urine analysis) with C/S (culture to identify specific type of infection and sensitivity to antibiotics) and CBC (complete blood count). Pt started on Cipro 500 mg po bid (by mouth twice a day) x 10 days. Pt resting quietly in bed tolerated well."


A physician order was found dated on 6/30/2020 at 1334 (1:34 PM). The order stated to discontinue the Foley catheter due to pain and hematuria by the nurse practitioner.


Review of the Daily Nurses Notes on 6/30/2020 at 1945 (7:45 PM), 6.5 hours after the removal that the catheter that the patient, had "not voided" and had "pain in his stomach." The nurse documented on the medication administration record (MAR) on 6/30/2020 at 2045 (8:45 PM) that the patient was administered regular Tylenol 650mg's for "7/10 (rated a 7 out of a 1 through 10 pain scale) lower abdominal pain." There was no documentation that the nurse observed the bladder for distention, observed for any blood clots in his brief or tinged urine, or obtained vital signs. The Daily nurses notes for "review of systems" was left blank. There was no documentation that the physician was notified.


Review of Patient #6's Multi-Disciplinary Notes dated 6/30/2020 at 2200 (10:00 PM) 8.5 hours later, the nurse documented that the patient had "urinated a large amount in the patients brief". A verbal order from the nurse practitioner on 7/1/2020 at 1415(2:15 PM) stated to replace the Foley catheter and administer "Tylenol #3 q (every) 6 hrs for pain prn (as needed)."


Review of Daily Nurses Note for 7/1/2020 8:50 AM revealed Staff #6 documented, "patient stated, 'I'm tired and played out." Patient had a blood pressure of 89/58. The patient stated he had a "8/10 pain level." There was no documentation that the patient was given anything for pain. There was no documentation that the physician was called concerning the episode of hypotension. There was no further documentation of the patient's vital signs or pain level until the next shift at 8:45 PM; 12 hours later.


Review of Patient #6's Observation Check Sheet/ Graphic Flowsheet revealed 35 out of 48 shifts did not have a documented time when vital signs were taken and documented.


Review of the treatment plan revealed there was a problem addressed for a "UTI" but there were no interventions to address the Foley catheter, bloody urine, intake and output of urine, or pain. Patient #6 was administered pain medication 23 times from 6/30/2020 to 7/15/2020 and was never addressed on the treatment plan.


Review of the multi-disciplinary notes dated 7/6/2020 at 1310 (1:10 PM) that the patient was being discharged to a Nursing facility for further care, but the Nursing Home required a negative COVID-19 test. A physician order was found on 7/6/2020 at 4:15 PM to administer a COVID-19 test. There was no nursing documentation that the test was administered, collected, or sent to the lab.


Review of the multi-disciplinary notes dated 7/7/2020 (no time documented) stated the patient now had a temperature of 100.7 and the nurse practitioner was notified. There was no documentation that anything was given for fever. There were no further vital signs documented until the next shift at 9:10 PM; temperature was 98.2.


Review of the physician orders revealed a verbal order dated 7/9/2020 at 6:06 PM per nurse practitioner. The order stated, "Place patient in Contact /Droplet Isolation d/t increased temp." review of the nurse's notes, and graphic flowsheet revealed Patient #6 had no documentation of an elevated temperature since 7/7/20.


Review of Patient #6's lab revealed the patient's COVID-19 test came back positive on 7/10/20.


Review of the treatment plan revealed there was nothing in the plan that addressed the patients COVID-19 diagnosis, isolation, Zithromax (antibiotic), and various medication changes.


Patient #6 was discharged to home and Hospice care on 7/16/20.

The facility failed to:

A. ensure nursing documented on a nursing plan of care the patients change in condition, positive COVID-19 diagnosis, treatment, isolation, falls, antibiotics, medication changes, IV fluid administration, oxygen administration, increased confusion, pain, and patient's response to treatment or interventions in 2 (Patient #1 and #6) of 2 charts reviewed.

Findings:

The facility has a Interdiciplinary care plan. The nursing care plan was included in the treatment team plan.

Patient #1

Patient #1 was admitted on 7/14/2020 as a voluntary patient with a diagnosis of Neurocognitive Disorder and a history of Dementia.

Review of Patient #1's Multi-Disciplinary Note dated 7/14/2020 at 1510 (3:10PM) revealed the patient was having chest pain and vital signs (V/S) "B/P 193/106 HR 89 R 18 T 98.4." The physician was notified and ordered Nitroglycerine sublingual and an EKG. Patient #1 stated the chest pain resolved at 1528 (3:28 PM). There was no further documented assessment concerning the chest pain or vital signs documented after 1510 (3:10PM) on 7/14/2020. Review of the "Observation Check Sheet/ Graphic Flowsheet revealed vital signs were taken between 7:00PM and 7:00AM but there was no time documented. The vital signs were "T-97.7, Pulse 57, Resp. 20, O2 sat 98 and a blood pressure of 166/99." Patient #1's B/P was still elevated but there was no evidence that the physician was aware. Review of Patient #1's Observation Check Sheet/ Graphic Flowsheet revealed 23 out of 34 shifts did not have a documented time when vital signs were taken and documented.


According to the American Heart Association the (Normal adult blood pressure is systolic of less than 120 and diastolic of less than 80 (120/80) Pulse rate Adults (age 18 and over) 60 - 100 beats per minute.


Review of the treatment plan revealed there was no documentation of the patient having chest pain and requiring nitroglycerine.

Patient #1 was tested for COVID-19 per Nursing Home request before he could be discharged on 7/24/2020.Review of the Nurses notes for both shifts revealed there was no documentation when the test was performed, who performed the test or how the patient tolerated the test.


Review of Patient #1's physician orders revealed an order on 7/24/2020 at 1633 (4:33PM) to place the patient in contact isolation due to a positive COVID-19 test. There was no nursing documentation on the day shift or night shift concerning the patient being placed in isolation, if the patient understood his diagnosis, any education done with the patient concerning his new diagnosis and isolation procedures, or how the patient tolerated the process. Review of the isolation policy and procedure revealed there was no update to the policy to include COVID-19 and isolation requirements for the facility.


Review of the treatment team plan revealed there was no documentation of the patient's new diagnosis of COVID-19, isolation, or education to patient or family.


Review of the Multidisciplinary Notes on 7/25/2020 at 11:05AM the nurse documented, "Pt found in his bathroom with lights off on the floor. Pt confused and in contact isolation. Pt had unwitnessed fall-pt states he hit his face and tried to get back up and hit his back. Pt found with partial pants down his leg stating Help me! Help me! I was trying to take a shower! Skin assessment done-small laceration noted to his right thumb. Pt requested to lay down assisted pt. to bed-placed bed alarm monitor and notified physician.


Review of Patient #1's physician orders revealed an order on 7/25/2020 at 12:04PM. The order read, "Pt. to be a 1:1 due to isolation and increase fall risk for 24 hrs. while awake." (1:1- the patient is visually within sight and within arms-reach of a staff member at all times and in all circumstances.)There was no documentation found on the nursing plan of care that the patient had a fall with injuries. There was no documentation that the patient was placed on a 1:1.


Review of Patient #1's physician orders revealed the nurse practitioner ordered the patient to be put on Zithromax (antibiotic), Prednisone (steroid), Pulmicort Inhaler (corticosteroid), Vit C and Zinc (vitamins). There was no documentation on the treatment team notes or nursing plan of care of the new medication and administration of an antibiotic.


Review of the Physician orders dated 7/25/2020 at 1446 (2:46PM) the nurse practitioner wrote "Start IV NS @ 125cc/hr x 1ltr (liter)-do not DC IV until reassessed." There was no documentation on the order or in the nurse's notes that gave a reason why Patient #1 was receiving an IV of normal saline. The nurse practitioner documented on her 7/26/2020 progress note that the patient was receiving fluids due to poor intake. Review of the nurses notes from admission to discharge stated the patients "Nutrition/Fluid: Adequate." There was no nursing documentation or assessment that discussed the patient's poor "po (oral) intake." Review of the treatment plan and nursing plan of care revealed no documentation of the patient's poor intake or IV therapy.


Review of the Daily Nurses Notes on 7/27/2020 at 12:45PM revealed Patient #1 now had a cough. Patient #1 had an elevated blood pressure of 167/96 and was confused. He was now being prompted for nutrition and fluids. Patient #1 has had a change in condition. The nurse practitioner saw the patient at 12:27PM but there was no documentation that there was a cough and no documentation that she or the physician was notified. On 7/27/2020 the nurse practitioner saw Patient #1 again and there is no documentation of cough. The nurse practitioner stated the lungs were clear to "auscultation (the listening of lung sounds with a stethoscope) and good air entry."


Review of the Observation Check Sheet/Graphic Flowsheet revealed on 7/27/2020 at 1907 (7:07PM), Patient #1 had a temperature of 100.2. There was no documentation in the nursing notes that the patient temperature was addressed or if the physician was notified of the change in condition.


On 7/29/2020 at 10:20AM a tour was conducted with Staff #2. Staff #4 a Mental Health Technician (MHT) was standing outside (in the hallway) of Patient #1's room (4B) in a disposable gown, shoe covers, gloves, N95 mask, head bonnet, and face shield. Staff #4 stated she was on a 1:1 with the patient due to a fall. Staff #4 stated the patient was COVID-19 positive and she had to stay by the patient's door with the door open, so she could see him. Staff #4 stated the patient had been confused and had been difficult to keep in his room. Staff #4 stated the patient had been out in the hallway with no mask several times, but the staff tried to intervene.There was no documentation in the nursing care plan addressing the patient's confusion and inability to follow instructions to stay in his room.


The surveyor observed Patient #1 was coughing in his room and had no mask on. He called the tech into the room and showed her he had coughed up some blood in a Kleenex. The tech called for the nurse.


Staff #6 did not take any equipment into the room. She talked to the patient and asked him questions. Staff #6 never took any vital signs or assessed the patient's lung sounds. The surveyor asked Staff #6 about 10 minutes later if she planned to assess Patient #1 and perform vital signs. Staff #6 instructed Staff #4 MHT to go into the room and take Patient #1's vital signs. Staff #4 brought a cart with the sphygmomanometer (instrument to measure blood pressure), thermometer, and pulse oximetry attached to Patient #1's room and took the patients vital signs. The surveyor did not observe Staff #6 assess Patient #1's lung sounds before her documentation at 11:30AM. The nurse failed to perform a thorough assessment. The nurse was unable to give the physician a clear and concise report to the physician without assessing the patient's lung sounds.


Review of the Multi-Disciplinary Note dated 7/29/2020 at 11:30AM Staff #6 documented, "Pt. assessed due to spitting small amount of bloody mucus. Pt in no distress- denies pain or SOB. Notified_____ (nurse practitioner) pt. to be cont to be monitored. Repeat vs b/p 145/84, p-73 O2 99 R-20 T-98. No new orders at this time." (sic)


Review of the Multi-Disciplinary Note dated 7/29/2020 at 1620 (4:20PM) revealed Staff #6 documented, "Pt states feel a little better. BP 133/80, R, 20, O2 99% T101.2 Tylenol given prn for temp." Patient had an active bloody cough and later developed a temperature of 101.2 with no evidence that the physician was notified.


Review of the Multi-Disciplinary Note dated 7/29/2020 at 2012 (8:12PM) the nurse documented the patient's oxygen saturation had dropped to 68% with a temperature of 103.2. The physician was called and an order for Oxygen 4L by nasal canula was ordered. The nurse documented, "Pt was compliant with Tylenol, but continuously removed the NC (nasal cannula)." The nurse documented in the Daily Nurse Note at 2216 (10:16PM) Pt agitated, constantly trying to get up. Stated "I hope to God one day you suffer like this." There was no documentation that the physician or the nurse practitioner came to the facility and assessed Patient #1.

.
According to the American Lung Association an oxygen level greater than 90% may be considered normal; anything below that would be a reason to call a doctor, and anything under 89% would be a reason to go to the emergency room.


Review of the nursing care plan revealed there was no documentation concerning elevated temperatures or decreased O2 staturations


Review of the Multi-Disciplinary Note dated 7/30/2020 at 6:30AM the nurse documented, "Monitored the patient throughout the night. O2 sat stayed between 79% and 82%. Pt remained verbally aggressive and removed NC several times. MHT attempted multiple times throughout the night to keep NC in place. Raised HOB, attempted to calm patient and encourage deep breathing. Continued O2 monitoring throughout the night. _____ (physician) notified that O2 sat came up to 82%. Pt was in no apparent distress, slept through the night."

Review of the physician orders re
vealed a verbal order, from the nurse practitioner, dated 7/30/2020 at 7:51AM stated, "Pt. to be sent to ER due to decreased O2 sat of 74% and hypoxia."


Review of the Multi-Disciplinary Note dated 7/30/2020 at 8:03AM revealed Staff #6 documented the patients O2 sat to be "89%." Pt was discharged to the local hospital on 7/30/2020 at 8:25AM.


Confirmation from the local hospital revealed Patient #1 had been admitted directly to the Intensive Care Unit upon arrival and died on 8/6/2020 @ 2345.



Patient #6

Review of Patient #6's chart revealed he was an 89-year-old male from a Nursing Home in Kilgore. He was admitted on 6/24/2020 for agitation, verbally and physically aggressive, and tried to choke a staff member at the Nursing Home. Patient #6 was admitted voluntarily. On the Daily Nurses Note, dated 6/25/2020 at 9:43AM, that the patient was "confused" and had "word salad." The social worker documented on 6/24/2020 that the patient was unable to answer questions due to cognitive impairment. Review of Patient #6's physician orders revealed he was admitted with a diagnosis of Bipolar I disorder with psychotic features and altered mental status unspecified. He was placed on assaultive precautions and 15-minute checks by the staff.


Review of patient #6's Multi-Disciplinary Notes dated 6/30/2020 at 4:20AM stated, "Pt c/o (complained of) lower abdominal pain. MHT reports dark blood coming from penis. Pt able to void in dribble manor. Pts bladder distended and winces when lightly palpated. Dr.____ (physician) notified. N.O. (new order) noted. 16 Fr Coude cath (a device inserted into the bladder to collect urine) inserted with indwelling cath return of dark bloody urine est 1300cc. Urine obtained for UA (urine analysis) with C/S (culture to identify specific type of infection and sensitivity to antibiotics) and CBC (complete blood count). Pt started on Cipro 500mg po bid (by mouth twice a day) x 10days. Pt resting quietly in bed tolerated well."


A physician order was found dated on 6/30/2020 at 1334 (1:34PM). The order stated to discontinue the Foley catheter due to pain and hematuria by the nurse practitioner.


Review of the Daily Nurses Notes on 6/30/2020 at 1945 (7:45PM), 6.5 hours after the removal that the catheter that the patient, had "not voided" and had "pain in his stomach." The nurse documented on the medication administration record (MAR) on 6/30/2020 at 2045 (8:45PM) that the patient was administered regular Tylenol 650mg's for "7/10 (rated a 7 out of a 1 through 10 pain scale) lower abdominal pain." There was no documentation that the nurse observed the bladder for distention, observed for any blood clots in his brief or tinged urine, or obtained vital signs. The Daily nurses notes for "review of systems" was left blank. There was no documentation that the physician was notified.


Review of Patient #6's Multi-Disciplinary Notes dated 6/30/2020 at 2200 (10:00PM) 8.5 hours later, the nurse documented that the patient had "urinated a large amount in the patients brief". A verbal order from the nurse practitioner on 7/1/2020 at 1415(2:15PM) stated to replace the Foley catheter and administer "Tylenol #3 q (every) 6 hrs for pain prn (as needed)."


Review of Daily Nurses Note for 7/1/2020 8:50AM revealed Staff #6 documented, "patient stated, 'I'm tired and played out." Patient had a blood pressure of 89/58. The patient stated he had a "8/10 pain level." There was no documentation that the patient was given anything for pain. There was no documentation that the physician was called concerning the episode of hypotension. There was no further documentation of the patient's vital signs or pain level until the next shift at 8:45PM; 12 hours later.


Review of Patient #6's Observation Check Sheet/ Graphic Flowsheet revealed 35 out of 48 shifts did not have a documented time when vital signs were taken and documented.


Review of the treatment plan reveled there was a problem addressed for a "UTI" but there were no interventions to address the Foley catheter, bloody urine, intake and output of urine, or pain. Patient #6 was administered pain medication 23 times from 6/30/2020 to 7/15/2020 and was never addressed on the nursing care plan.


Review of the multi-disciplinary notes dated 7/6/2020 at 1310 (1:10 PM) that the patient was being discharged to a Nursing facility for further care, but the Nursing Home required a negative COVID-19 test. A physician order was found on 7/6/2020 at 4:15PM to administer a COVID-19 test. There was no nursing documentation that the test was administered, collected, or sent to the lab.


Review of the multi-disciplinary notes dated 7/7/2020 (no time documented) stated the patient now had a temperature of 100.7 and the nurse practitioner was notified. There was no documentation that anything was given for fever. There were no further vital signs documented until the next shift at 9:10PM; temperature was 98.2.


Review of the physician orders revealed a verbal order dated 7/9/2020 at 6:06PM per nurse practitioner. The order stated, "Place patient in Contact /Droplet Isolation d/t increased temp." review of the nurse's notes, and graphic flowsheet revealed Patient #6 had no documentation of an elevated temperature since 7/7/20.


Review of Patient #6's lab revealed the patient's COVID-19 test came back positive on 7/10/20.


Review of the treatment plan revealed there was nothing in the plan that addressed the patients COVID-19 diagnosis, isolation, Zithromax (antibiotic), and various medication changes.


Patient #6 was discharged to home and Hospice care on 7/16/20.

Based on review of records, observations, and interviews, the facility failed to ensure the infection control program sufficiently addressed the highly transmittable COVID-19 virus. The facility failed to:

A) conduct a facility-wide risk assessment specific to COVID-19 in order to properly assess and evaluate potential COVID-19 risks specific to each of the facility departments/operations.

B) use findings from a specific facility risk assessment and national COVID-19 standards (such as guidelines from the Centers for Disease Control) to develop a comprehensive COVID-19 response plan, policies, and/or procedures for facility staff to follow.

C) develop, implement, and enforce Transmission-Based Precautions for known and suspected cases of COVID-19 for 18 out of 18 patients (Patients # 1 through #18) with known or suspected COVID-19.

D) provide education to patients, family, and staff members on COVID-19 symptoms to report per national COVID-19 standards.

E) screen patients, visitors, and staff member for COVID-19 symptoms per national COVID-19 standards prior to entering the facility.

F) ensure the processes that had been established by the facility were enforced.

G) establish quality monitors for the tracking of COVID-19 related symptoms and processes to ensure early detection and comprehensive interventions to prevent the spread of COVID-19 among all patients and staff.

The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Cross Refer to Tag A0749 for specific findings.

Based on review of records, observations, and interview, the facility failed to:

A) conduct a facility-wide risk assessment specific to COVID-19 in order to properly assess and evaluate potential COVID-19 risks specific to each of the facility departments/operations.


B) use findings from a specific facility risk assessment and national COVID-19 standards (such as guidelines from the Centers for Disease Control) to develop a comprehensive COVID-19 response plan, policies, and/or procedures for facility staff to follow.


C) develop, implement, and enforce Transmission-Based Precautions for known and suspected cases of COVID-19 for 18 out of 18 patients (Patients # 1 through #18) with known or suspected COVID-19.


D) provide education to patients, family, and staff members on COVID-19 symptoms to report per national COVID-19 standards.


E) screen patients, visitors, and staff member for COVID-19 symptoms per national COVID-19 standards prior to entering the facility.


F) ensure the processes that had been established by the facility were enforced.


G) establish quality monitors for the tracking of COVID-19 related symptoms and processes to ensure early detection and comprehensive interventions to prevent the spread of COVID-19 among all patients and staff.


The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


Findings for A):

On the morning of 8-7-2020, an interview was conducted in the conference room with Staff #1, Staff #2, Staff #13, and Staff #14 present. Staff were asked who in the facility was assigned and responsible for monitoring the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) websites for updated COVID-19 Guidelines and Recommendations.


Staff #13 stated that the corporate Infection Control Specialist was the person who monitored those websites and updated facilities on changing recommendations and guidelines. Staff #2 was asked if she monitored the websites and made recommendations to the corporate Infection Control Specialist. Staff #2 stated that she looks at the CDC website occasionally, but confirmed that she did not make any recommendations based off the information she reviewed.


Staff #2 was provided a copy of the CDC pamphlet titled, "Comprehensive Hospital Preparedness Checklist for Coronavirus Disease 2019 (COVID-19)". The purpose of the checklist was:


"Planning for a community outbreak of Coronavirus Disease 2019 (COVID-19) is critical for maintain healthcare services during a response. The Centers for Disease Control and Prevention (CDC), with input from partners, has developed a checklist to help hospitals (acute care facilities) assess and improve their preparedness for responding to a community-wide outbreak of COVID-19. Because of variability of outbreaks, as well as differences among hospitals (e.g., characteristics of the patient populations, size of the hospital/community, scope of services), each hospital will need to adapt this checklist to meet its unique needs and circumstances. This checklist should be used as one of several tools for evaluating current plans or in developing a comprehensive COVID-19 preparedness plan. Additional information can be found at www.cdc.gov/coronavirus."

Staff #1 and Staff #14 confirmed that they had not seen the checklist before and that an assessment of the facility's physical environment and operations had not been evaluated using the checklist or a similar checklist designed to analyze and prepare facilities for a COVID-19 outbreak.


Findings for B):

On 8-7-2020, an interview was conducted with Staff #1, Staff #2, and Staff #13 present in the facility conference room. A policy titled Coronavirus COVID-19, Policy Number: IC-01.05, Effective Date: 03/17/2020 was reviewed. The stated purpose of the policy was:

"To outline specific steps taken to safeguard patient and employee health and well-being during an outbreak while ensuring the ability to maintain operations and continue providing essential services to patients. In addition, it provides guidance on how to respond to specific operational and Human Resource (HR) issues."


Under Policy:

"The hospital will follow all current guidance from the Centers for Disease Control and Prevention (CDC), World health (sic) Organization (WHO), Occupational Safety and Health Administration (OSHA) and other applicable Federal, State and Local Departments of Health."


Under Procedures:

"1. Infection prevention and control policies and training for healthcare workers (HCWs):

a. Hospital leadership including the Chief Medical Officer, Infection Control Coordinator, hospital administration and department directors will follow the Centers for Disease Control and Prevention's (CDC's) COVID-19 guidance.
https://www.cdc.gov/coronavirus/2019-nCoV/guidance-hcp.html
...

6. Monitoring and managing HCWs:

a. The hospital will follow the local/state public health authority's policies and procedures for monitoring and managing HCWs with potential for exposure to COVID-19, including ensuring that HCWs have ready access, including via telephone, to medical consultation.
...

8. Hospital will regularly monitor the situation on CDC's coronavirus disease (COVID-19) web page: www.cdc.gov/COVID19"



Procedures 1, 6, and 8 reference other agency's websites, policies, procedures, and guidance. Staff #2 and Staff #13 confirmed that no one in the hospital had been assigned responsibility for monitoring the referenced outside sources. Staff #2 and Staff #13 both stated that the corporate Infection Control Preventionist monitored the CDC website and sent emails notifying the facility of changes to information. However, the specific guidance from the outside sources were never incorporated into specific policies, procedures, or interim guidance until the COVID-19 policy could be updated.


Staff #2 and Staff #13 stated, they used CDC guidelines, but could not reference specific guideline documents from the CDC websites that were applicable to their facilities. The CDC websites that were referenced in the facility policy directed the user to a general page that had links to numerous resources. The policy did not include the specific resources to be used by the facilities or specific guidance to be used.


Findings for C):

During a tour of the facility on 7/29/20 the surveyors were informed by administration that there were three patients currently in the building with a positive test of COVID-19. Staff #1 and Staff #2 stated they do not have specific policy and procedures in care for the COVID-19 patients but are following the CDC guidelines.


During an interview on 7/29/20 at 10:10 AM Staff #1 stated the patients were isolated to their rooms. Staff #1 stated it was hard to keep them in their rooms sometimes and they must be redirected to their rooms. Staff #1 reported when the patients test positive for COVID-19 they try to find a safe discharge option for the patients but there are times the facilities (Nursing Home) won't take them back. The family members find out and refuse to take the patients back home. Staff #1 stated that she has had Staff out with COVID-19, and she has been short staffed, or they just quit. However, Staff #1 confirmed that she has not stopped admissions due to lack of staff or COVID-19 exposures.


Review of the patient census for 7-14-2020 showed that 6 patients (Patient # 4,5,6,10,11 and 14) were positive for COVID-19. The facility admitted 5 patients (Patient #1,15,16,17, and 22) the same day, 7-14-2020.


Patient #1 was tested for COVID-19 on 7/24/2020 due to cough and fever. The results came back on the same day 7/24/2020. Patient #1 was confirmed as positive. He was transferred to a local medical hospital on 7/29/2020 due to bloody sputum and decreased blood oxygen levels. He died at the local hospital on 8/6/2020.


Patient #15 was tested for COVID-19 on 7/20/2020 due to a cough with negative results returned on 7/20/2020. The patient was discharged home on 7/25/2020.


Patient #16 was tested for COVID-19 on 7/23/2020 due to a cough with negative results returned on 7/23/2020. The patient was discharged home on 7/28/2020.


Patient #17 was tested for COVID-19 on 7/27/2020 due to a fever with negative results returned on 7/27/20. The patient was discharged on 7/29/2020.


Patient #22 was never tested and was still there as a patient on 7/31/2020.


Dayroom

On 7/29/20 at 10:20 AM the surveyors entered the Dayroom. Upon entering there were patients sitting close to one another on couches and chairs around tables. Some patients were wearing mask and others were not. The day room flowed into the patient hallway to patient rooms. Staff were walking on and off the unit with mask on, but two employees were observed leaving the unit without washing their hands or using antiseptic gel.


Patient Rooms and Hallway

The dayroom and nurses station flowed into the patient hallway. The hallway had a set of double wooden doors in the middle and a back-door exit. One of the double doors was open on one side. Staff and patients were observed walking up and down the hallway.

Patient #1, #7 and #8 were the current COVID-19 positive patients. These patients were supposed to be in isolation. The COVID-19 patient rooms were not segregated from the well patients. Patient #1 was in room 4B, Patient #7 was in 10B and Patient #8 was in 11B. The COVID-19 positive patients room doors were open to the hallway where well patients and staff were walking.


Patient #7's (10B) door was open and a running floor fan was found sitting in front of the patient's door. The fan was pulling air from the positive COVID-19 patient's room, blowing air down the patient hallway allowing germs to be spread. Staff #2 was shown the fan blowing on the floor. Staff #2 stated, "yeah, I guess they were mopping the floor and left it unattended." Staff #2 was asked if she thought that was cross contamination and causing the infectious airborne disease to spread in the facility and she stated, "It could be." She never turned off the fan until prompted by surveyor. Staff #2 was shown that there was also a radio in Patient #7's room sitting on his trash can plugged in. Staff #2 confirmed they had put a radio, with a cord, in a suicidal patient's room unattended. There were no cleaning procedures for the radio being brought in and out of the patient's room. Staff #2 stated, "we just wipe it down with a wipe."


Staff #4 a Mental Health Technician (MHT) was standing outside (in the hallway) of Patient #1's room (4B) in a disposable gown, shoe covers, gloves, N95 mask, head bonnet, and face shield. Staff #4 stated she was on a 1:1 with the patient due to falls. Staff #4 stated the patient was COVID-19 positive. There was no visible hand gel or place for the MHT to wash her hands. Staff #4 was asked how she washed her hands. Staff #4 reported that she washes her hands in the (contaminated) patient room or puts her (contaminated) hands in and out of her pockets to use a gel. During an interview with Staff #4 she was observed walking in and out of Patient #1's room without donning or doffing. When putting on PPE (Personal Protective Equipment) you (don) and when you take off (doff). There was no visible place for the MHT to "don or doff" her PPE. There was no visible evidence on where the contaminated PPE, linen, or trash was disposed of.


In the hallway, a PPE cart was observed. The cart was locked. The MHT unlocked the cart with the same dirty gloves and PPE she was wearing in the patient room. Inside the cart was PPE and two bottles of hand sanitizer with broken pumps on top. The MHT and Infection control nurse opened the clean cart, placed their dirty hands inside the clean cart, manually pulled the sanitizer pump off the bottle causing contamination of the cart. If the staff chose to use the sanitizer in the cart, they would have to wipe their hands down the pump tubing to get any gel causing contamination inside the cart and the whole bottle of gel. No one wiped the cart down after contaminated hands were on and inside the cart.


During our interview with Staff #4, she was called into the room by Patient #1. She talked to him and handled a Kleenex he gave her that had bloody sputum in it. She laid the Kleenex down and came to the outside of the door. She removed her contaminated gloves but did not remove any other PPE. She put her hands in her pockets while still wearing a dirty gown, pulled out antiseptic hand gel, used it, and placed it back in her pocket contaminating the pocket and gel. Staff #4 never washed her hands and put back on clean gloves. Staff #4 called for Patient #1's nurse to come to the room due to Patient #1 coughing up bloody sputum. Staff #4 stated this was a change in Patient #1 and he had not had a bloody sputum before.


Staff #6 (RN) came down the hallway and asked the MHT what was wrong. Staff #6 proceeded to open the PPE cart. She tried 3 times to unlock the cart and then asked the MHT if the cart was locked. She then tried 2 more times to open the cart and was unable to put in the correct code. Once the cart was opened, she proceeded to put on her PPE and enter the room. Staff # 6 took 17 minutes to perform the task of opening the cart and donning on.


Staff #6 did not take any equipment into the room. She talked to the patient and asked him questions. Staff #6 never took any vital signs or assessed the patient. As Staff #6 was coming out of the room she stood in doorway and asked the MHT where the doffing box was for the PPE. Staff #2 was watching Staff #6 when she was coming out of the room. Staff #2 gave no direction to Staff #6 nor did she go and get any trash receptacles for Staff #6 to place her contaminated PPE in. Staff #4 stated that Staff # 2 had taken the contaminated trash barrel away just a short while ago. The staff was putting contaminated PPE in the barrel.


Staff #6 walked out of the contaminated room with her contaminated PPE on and walked down the clean hallway, touched the clean door keypad with her dirty glove, walked down another hallway, entered the soiled linen room with her contaminated PPE and doffed off. Inside the soiled linen room, a large rolling trash can was found with a lid. There were two overfilled closed black trash bags filled with dirty PPE in the can. Staff #6 had doffed her dirty PPE and just stuck it between the two closed trash bags. She did not remove her PPE properly and place into a sealed bag or container leaving that PPE exposed and potentially falling onto the floor. She washed her hands in the dirty room. She walked back out with her contaminated face shield in her hand. The surveyor asked her what she was going to do with the face shield then she stated, "oh, I guess I need to leave it in there." She went back into the soiled room and left the face shield not washing or applying gel to her contaminated hands. Staff #2 touched the dirty keypad with her bare hands to open the door and never washed her hands or used gel. The keypad, door handles, nor the PPE cart was wiped down or removed from the area. Staff #6 walked back up to the nurse's station after exit from the soiled linen room. Staff #2 stated that she had moved the PPE can into the soiled linen room because it was overfilled and in the hallway. Staff #2 confirmed she did not replace the can or trash receptacle for use. Staff #2 stated they had been using the rolling can and had not left contamination boxes in the rooms for soiled PPE or linen. Staff #2 stated she was not sure how many boxes she needed to place in the patient rooms. Approximately 20 minutes later Staff #2 placed clean boxes for contaminated trash and PPE in 2 of the 3 rooms.


The surveyor asked Staff #6 about 10 minutes later if she planned to assess Patient #1 and perform vital signs. Staff #6 instructed Staff #4 MHT to go into the room and take Patient #1's vital signs. Staff #6 was never observed assessing Patient #1's lung sounds or vital signs.


Staff #4 brought a cart with the sphygmomanometer, also known as a blood pressure meter, thermometer, and pulse oximetry attached to Patient #1's room. Staff #4 rolled in the equipment and used it on the patient in a contaminated room. Staff #4 brought the cart out and proceeded to wipe the top of the cart down with a sanitizing wipe using her same PPE. Staff #4 was asked how she was trained to clean the cart and she stated she wipes it all down when she is finished and then it is taken back up to the nurse's station. Staff #4 and #2 were shown the cart. The stand and bottom of the cart was visibly soiled with dirt, dust and hair. There were dried, spilled liquids on the stand. The wheels of the cart where so caked with dirt, dust, and hair that it looked like dried mud. Staff #4 and #2 confirmed the filth of the vital sign cart. Staff #2 stated, "I never saw that. I guess I just missed that." Staff #4 was asked if she had any disposable stethoscopes, blood pressure cuffs or thermometers to leave securely in the isolation room. Staff #4 stated she was not aware if they had any. Staff #4 and #2 confirmed that the same vital sign cart was being used for well and COVID-19 positive patients.


Staff #2 showed the clean supply room to the surveyors. There was PPE available. Staff #2 was asked when the goggles and other PPE arrived for use and she stated, "We got it all two days ago. We got it from the RAC." (Regional Advisory Council for disaster preparedness)


Housekeeping

An interview was conducted with Staff #14 on the morning of 7/30/20. Staff #14 stated that he had 3 fulltime housekeepers and 1-part time. Staff #14 stated that he has had several of his staff out with COVID-19 and had to utilize the MHT's for cleaning.


Staff #14 stated that the employees get infection control training at general orientation and then "on the job training." Staff #14 stated that he had gone over appropriate cleaning for a terminal clean and isolation with his housekeeping staff. Staff #14 stated he just did the training verbally but had no documented proof. There was no education on COVID-19 or isolation training in the employees file. Staff #14 stated he had no competencies or policy and procedure for the MHT staff on how to clean a terminal isolation room.

Review of the policy and procedure Housekeeping Services-General Cleaning" policy number EOC-78 revised date 6/1/19 revealed general housekeeping duties for the facility but there was no information on cleaning an isolation room or an active COVID-19 patient room.


Staff Interviews

Confidential interviews with staff were conducted from 7/29/20-7/30/20 concerning infection control due to fear of retaliation. Staff stated that they had not been issued full PPE until a "couple" of days ago. Staff had been buying their own mask and hand gel. Staff confirmed the patients that had positive COVID-19 test would walk out into the dayrooms, up and down hallways with no mask on. Staff stated administration told them to redirect the patients and try to get them into the rooms, but they could not force them. Staff confirmed they had not had any COVID-19 training nor any cleaning instruction on how to clean an isolation room.


Staff stated that they had suggested to separate the patients and put all the sick patients in one area, but administration would not listen to them. Staff stated they were reluctant to say they had any symptoms because the facility would not pay for the COVID-19 test and send them home with no pay. Staff stated they were unaware of their options. Staff stated they were sent text by the staffing coordinator that stated the following:

"Monday 7/6/20 at 3:58 PM Hi everyone! I just want to give you a heads up regarding the guidance we received this morning on COVID-19 testing. If you decide to get tested and are asymptomatic, (not experiencing symptoms) you will need to be off work for 10 days WITHOUT pay or until you receive negative results. We are not saying do not get tested especially if you are experiencing symptoms but just want you to be aware that regardless you will be required to be off work for 10 days. I also want to add if you are getting tested for peace of mind and have no symptoms, we don't need to know unless you develop symptoms are test positive."

Staff stated they were confused by this and just didn't tell anybody anything. Staff confirmed there was no clarification from this text from the Director of Nursing (DON) or the Administrator. Staff stated they were not sure if Staff #3 was the DON or if Staff #5 was.


Review of the staffing sheets showed staff coming to work with fevers. One staff member stated they had a temperature for a couple of days and a bad headache, but Staff #5 told her to put her mask on and take some Tylenol. The timecard was pulled, and the staff member worked in direct contact with patients.

According to the CDC https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html

"Recommendation number, description, and category for standard precautions for hand hygiene.

IV.A.1. During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces.

IV.A.2. When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water.

IV.A.3. If hands are not visibly soiled, or after removing visible material with nonantimicrobial soap and water, decontaminate hands in the clinical situations described in IV.A.4.a-f. The preferred method of hand decontamination is with an alcohol-based hand rub. Alternatively, hands may be washed with an antimicrobial soap and water.

IV.A.3 Perform hand hygiene ~ in the following clinical situations:

IV.A.3.a. Before having direct contact with patients

IV.A.3.b. After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings.

IV.A.3.c. After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient).

IV.A.3.d. If hands will be moving from a contaminated-body site to a clean-body site during patient care.

IV.A.3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

IV.A.3.f. After removing gloves

IV.A.4. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores."


Findings for D):

On 8-7-2020 an interview was conducted with Staff #1, Staff #2, and Staff #13 present in the facility conference room. Staff #1, Staff #2, and Staff #13 confirmed that CDC guidelines and recommendations for COVID-19 were being followed.


A policy titled Coronavirus COVID-19, Policy Number: IC-01.05, Effective Date: 03/17/2020 was reviewed. The stated purpose of the policy was:

"To outline specific steps taken to safeguard patient and employee health and well-being during an outbreak while ensuring the ability to maintain operations and continue providing essential services to patients. In addition, it provides guidance on how to respond to specific operational and Human Resource (HR) issues."


"POLICY:

The hospital will follow all current guidance from the Centers for Disease Control and Prevention (CDC), World health (sic) Organization (WHO), Occupational Safety and Health Administration (OSHA) and other applicable Federal, State and Local Departments of Health.
...
PROCEDURE:
...
2. Process for rapidly identifying and isolating patients with suspected COVID-19
a. Signs are posted at entrances with instructions to individuals with symptoms of respiratory infection to immediately put on a mask and keep it on during their assessment, cover their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after contact with respiratory secretions.

b. Facemasks are provided to coughing patients and other symptomatic individuals upon entry to the hospital.

c. Signs are posted in entrance assessment areas advising patients with fever or symptoms of respiratory infection and recent travel outside the US, specifically to China, to immediately notify personnel so appropriate precautions can be put in place."


Review of Oceans' COVID-19 COMPREHENSION CHECK test given to staff on 7-29-2020 and 7-30-2020 showed that staff were only required to show comprehension of 3 COVID-19 symptoms. Question #7 was as follows:

"7. What are symptoms of COVID-19 (select all that apply)
a. Cough
b. Fever
c. Chest pain
d. Shortness of breath
e. Loss of sense of taste/smell"

The correct answer was identified as a.; b.; d.; and e.


The CDC's COVID-19 website lists the symptoms to watch for as follows:

"Symptoms of Coronavirus
Watch for symptoms

People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:

Fever or chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea


This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19 ..."


No information for patients, staff, or visitors was found displayed that identified the CDC listed symptoms to watch for and/or report such as the posters available at the cdc.gov/coronavirus website. Resources at the website provided educational posters to include one listing the following symptoms to report:

"IF YOU HAVE
Fever or Chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

Please call our office before coming inside."


Findings for E):

On 7/29/2020 at 9:05 AM, surveyors entered the facility without any screening questions related to COVID-19 or a temperature check.

An interview was conducted with Staff #1 and Staff #2 on 7/29/2020 after 9:30 AM. Staff #2 was asked if the facility had a screening process in place for visitors and staff that had to be completed upon entering at the front lobby. Staff #2 replied, "Yes we do. Anyone that works up front comes through the front door and checks their temperature and logs it in a notebook. Clinical employees, Nursing and Mental Health Techs, enter in the back door and check their own temperatures and log it in a book. Sometimes the charge nurse does the temperature checks on the employees and she will log it into the book."


Staff #1 was asked if there were any screening questions asked regarding symptoms or exposure to COVID-19 to employees and visitors. Staff #1 stated, "All of the employees had to complete a questionnaire in June regarding symptoms or exposure to COVID-19, but it is not completed daily. We only take temperatures daily. The employees are told to contact the Infection Control Nurse or their direct supervisor if they become symptomatic."


A review of the document titled, "Daily Temperature Checks" revealed on May 6, 2020 Staff #15 recorded a temperature of "101.6 Tylenol Recheck 99.0 F". Staff #2 confirmed Staff #15 worked a 12-hour shift in direct patient care on May 6, 2020.


An interview was conducted with Staff #2 on 7/30/2020 after 10:00 AM. Staff #2 was asked if Staff #15 completed a COVID 19 screening related to symptoms and exposure before starting her scheduled shift on May 6, 2020. Staff #2 replied, "I don't think she did." After multiple requests, no documentation of employee screening questions related to COVID 19 symptoms and exposure was presented for review.


Further review revealed no temperature checks were completed on any employee entering the facility through the back entrance between May 16, 2020 and July 1, 2020. Further review revealed no temperature screenings on employees entering through the back entrance were logged from July 3, 2020 through July 13, 2020. An interview was conducted with Staff #2 on 7/30/2020 after 10:00 AM. Staff #2 was asked if the temperature logs were complete and accurate. Staff #2 replied, "Yes, they are. We did not do any temperature logs for the month of June but in July we have done better since we had an employee and patient test positive for COVID-19."


Staff #2 confirmed no screening temperatures were logged on any employee entering through the back entrance on May 16, 2020 through July 1, 2020, and July 3, 2020 through July 13, 2020. In addition, no temperature screenings were completed on July 15, 16, 18, or 19, 2020.


Staff #2 confirmed she does not regularly monitor the screening tools used.


Staff #1 and Staff #2 confirmed the above findings.


An interview was conducted with Staff #4 and #7 on 7/29/2020 after 11:00 AM. Staff #4 and Staff #7 was asked if they checked their own temperature and answered screening questions for COVID-19 before starting their scheduled shifts. Both employees replied they do check their temperature most of the time and write it in a book, but not every day.

A review of the facility policy titled, "Coronavirus COVID-19" with an effective date of 3/17/2020 was as follows:


" ...PROCEDURE:

1. Infection prevention and control policies and training for healthcare workers (HCWs):

a. Hospital leadership including the Chief Medical Officer, Infection Control Coordinator, hospital administration and department directors will follow the Centers for Disease Control and Prevention's (CDC's) COVID-19 guidance.


6. Monitoring and managing HCWs:

c. The hospital will conduct symptom and temperature checks prior to the start of any shift of asymptomatic, exposed HCW's that are not work restricted ..."


A review of the CDC's current recommendations revealed:

" ...Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic

1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic.
...
Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19
...

Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand sanitizer (ABHS) with 60-95% alcohol, tissues, and no-touch receptacles for disposal, at healthcare facility entrances, waiting rooms, and patient check-ins.

Limit and monitor points of entry to the facility.

Consider establishing screening stations outside the facility to screen individuals before they enter.

Screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with SARS-CoV-2 infection and ensure they are practicing source control.

Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature ?100.0°F or subjective fever.

Ask them if they have been advised to self-quarantine because of exposure to someone with SARS-CoV-2 infection."

A hyperlink was listed under the statement "Screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms" which listed the following symptoms:

"Symptoms of Coronavirus
Watch for symptoms
People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19 ..."

Staff #1 and Staff #2 confirmed the above findings.


On 8-7-2020, a review of the Pre-Admission Screening Assessment was made. The document had an added page titled, "Patient Screening for Coronavirus COVID-19." The form required the Pre-

Based on document review and interview the facility failed to follow their own policy to ensure treatment plans were updated through treatment team meetings. The facility failed to ensure treatment team meetings were held weekly and as needed to assess psychiatric status, effectiveness of treatment modalities, prescribed medications, and changes in patient conditions that were appropriate for patients care needs in 2 (Patient #5 and #6) of 3 medical records reviewed.


Findings Include:

PATIENT #5

A review of Patient #5's medical record revealed Patient #5 was admitted on 6/7/2020 with a diagnosis of Dementia. Patient #5 was discharged on 7/15/2020. A Multidisciplinary Integrated Treatment Plan was initiated on 6/7/2020 and signed by Patient #5 and Staff Registered Nurse (signature illegible) on 6/7/2020 and signed by the MD (signature illegible) on 6/10/2020.

A review of Patient #5's medical record revealed a Treatment Plan Review and Update was completed on 6/10/2020, 6/17/2020, and 6/24/2020. No treatment team review or update after 6/24/2020 was located in the medical record.

Further review of Patient #5's medical record revealed Patient #5 remained an active inpatient for 21 days after the last updated Treatment Plan on 6/22/2020.



PATIENT #6

A review of Patient #6's medical record revealed:

Patient #6 was an 85-year-old male admitted on 7/7/2020 with a diagnosis of Dementia with Behaviors. Patient #6 was placed on Violence/Homicide and Falls precautions with an observation/monitoring level of every 15 minutes.

A review of the History and Physical documented dated 7/8/2020 at 9:51 AM by Staff #20 was as follows:

" ...85-year-old male with dementia referred for increased agitation, unable to redirect at times, delusional, decreased sleep, worries a lot, racing thoughts, increased anxiety, decreased appetite, guarded, verbally and physically aggressive, sundowning, pacing, restless, combative ..."

A review of the document titled, "Oceans Physicians Order" dated 7/8/2020 at 4:00 PM was as follows:

" ...OPC (Order of Protective Custody)Pt (Patient) lack Capacity
Trazadone (a sedative commonly 50mg PO Q bedtime PRN sleep
Right arm sling per Lisa ..."

Illegible physician/provider signature documented on order.

Orders were noted by staff on 7/8/2020 at 16:30 (4:30 PM) but no signature of staff acknowledging the order was documented.


Further review of the medical record revealed a document titled, "Medical Progress Note" documented by Staff #20 dated 7/9/2020 at 12:28 PM was as follows:

" ...Got a report from family that he has a shoulder fx (fracture) but we have no confirmation of that. A sling has been placed on right arm but he is not wearing it appropriately ...."


No documentation was found on the Interdisciplinary Treatment Team Update with Physician Certification dated 7/16/2020 informing the treatment team of a shoulder fracture or the need to wear an arm sling. The Treatment Team Update was signed by Staff #21, #22, #23, #24, and certified by Staff #19.


No documentation was found within the medical record of an increase in observation levels for safety concerns. Patient #6 was admitted to the facility for increased agitation and physical aggression. Without constant monitoring of Patient #6, the said arm sling could have been used as a weapon or ligature device. This placed all patients and staff at a heightened risk of serious harm or death.


A review of the policy titled, "Treatment Team Staffing and Reassessment" with a revised date of 2/1/2020 was as follows:

" ...POLICY:
The Program Director or Director of Clinical Services, along with each attending physician will direct and supervise the treatment staff team for that physician's patients. They will lead and direct the treatment planning process and implementation of the treatment plan. The multidisciplinary treatment team is comprised of each discipline involved in the patient's care.

Each member of the multi-disciplinary treatment team shall evaluate, review, and update the treatment plan on an ongoing basis, when significant changes in the individual's condition, diagnosis, or care occurs and at least every seven days for inpatient and PHP and every 31 days for IOP. Reassessment will also occur at other times when significant change occurs in an individual's condition or diagnosis or at other key decision points ..."


An interview was conducted on 7/29/2020 after 10:00 AM with Staff #1. Staff #1 was asked how often Treatment Team meetings were being held. Staff #1 stated, "All treatment team meetings are held every Wednesday for all inpatients."

Staff #1 confirmed the above findings.